Severe gastric insufflation and consequent atelectasis caused by gas leakage using AIR-Q laryngeal mask airway:A case report

BACKGROUND The airways of patients undergoing awake craniotomy(AC)are considered“predicted difficult airways”,inclined to be managed with supraglottic airway devices(SADs)to lower the risk of coughing or gagging.However,the special requirements of AC in the head and neck position may deteriorate SADs’seal performance,which increases the risks of ventilation failure,severe gastric insufflation,regurgitation,and aspiration.CASE SUMMARY A 41-year-old man scheduled for AC with the asleep–awake–asleep approach was anesthetized and ventilated with a size 3.5 AIR-Q intubating laryngeal mask airway(LMA).Air leak was noticed with adequate ventilation after head rotation for allowing scalp blockage.Twenty-five minutes later,the LMA was replaced by an endotracheal tube because of a change in the surgical plan.After surgery,the patient consistently showed low tidal volume and was diagnosed with gastric insufflation and atelectasis using computed tomography.CONCLUSION This case highlights head rotation may cause gas leakage,severe gastric insufflation,and consequent atelectasis during ventilation with an AIR-Q intubating laryngeal airway.

Assessment of the Effects of Manual Chest Compression Technique on Atelectasis in Infants: A Randomized Clinical Trial

Objectives: To evaluate the effect of manual chest compression (MCC) in the variables of oxygenation, hemodynamic and respiratory effeteness in infants suffering from respiratory diseases with atelectasis. Methods: Controlled clinical trial, in which 38 infants were evaluated,19 ineach study group (group A: atelectasis and group B: control). Data were measured before, immediately after and 10 minutes after the end of the technique’s application. Results: The average age was of 5.05 months. There was an increase of RR in group A immediately after the application of the technique and signs of respiratory distress with a decrease in the oxygen saturation. Conclusion: There was a reduction in SpO2, an increase of RR and a worsening of clinical signs of respiratory distress. Given this, one may consider that there is a controversy about the benefits, mechanism of action, physiological and therapeutic effects of MCC when applied to infants.

Pleural empyema with endobronchial mass due to Rhodococcus equi infection after renal transplantation: A case report and review of literature

BACKGROUND Kidney transplantation is the best option for patients with end-stage renal disease.However,the need for lifelong immunosuppression results in renal transplant recipients being susceptible to various infections.Rhodococcus equi(R.equi)is a rare opportunistic pathogen in humans,and there are limited reports of infection with R.equi in post-renal transplant recipients and no uniform standard of treat-ment.This article reports on the diagnosis and treatment of a renal transplant recipient infected with R.equi 21 mo postoperatively and summarizes the charac-teristics of infection with R.equi after renal transplantation,along with a detailed review of the literature.Here,we present the case of a 25-year-old man who was infected with R.equi 21 mo after renal transplantation.Although the clinical features at the time of presentation were not specific,chest computed tomography(CT)showed a large volume of pus in the right thoracic cavity and right middle lung atelectasis,and fiberoptic bronchoscopy showed an endobronchial mass in the right middle and lower lobe orifices.Bacterial culture and metagenomic next-generation sequen-cing sequencing of the pus were suggestive of R.equi infection.The immunosup-pressive drugs were immediately suspended and intravenous vancomycin and azithromycin were administered,along with adequate drainage of the abscess.The endobronchial mass was then resected.After the patient’s clinical symptoms and chest CT presentation resolved,he was switched to intravenous ciprofloxacin and azithromycin,followed by oral ciprofloxacin and azithromycin.The patient was re-hospitalized 2 wk after discharge for recurrence of R.equi infection.He recovered after another round of adequate abscess drainage and intravenous ciprofloxacin and azithromycin.CONCLUSION Infection with R.equi in renal transplant recipients is rare and complex,and the clinical presentation lacks specificity.Elaborate antibiotic therapy is required,and adequate abscess drainage and surgical excision are necessary.Given the recurrent nature of R.equi,patients need to be followed-up closely.

儿童气管异物合并急性阻塞性肺不张的临床表现及治疗

阻塞性肺不张是儿童气管、支气管异物常见的并发症之一[1,2],缓慢发生或小块肺不张时,一般无明显症状,但当急性大面积肺不张则可产生缺氧、胸闷、紫绀和心动过速等症状,偶可引起循环衰竭,需尽早经气管镜取出异物,去除致肺不张因素,促使肺复张。我院自2007年7月～2010年8月收治气管异物患儿共2011例,其中24 h内合并有急性肺不张的气管异物患儿共6例,发病率0.29%,现将病例讨论如下。

Management and outcome of bronchial trauma due to blunt versus penetrating injuries

BACKGROUND The number of patients with bronchial trauma(BT)who survived to hospital admission has increased with the improvement of prehospital care;early diagnosis and treatment should be considered,especially among blunt trauma patients,whose diagnosis is frequently delayed.AIM To describe the early recognition and surgical management considerations of blunt and penetrating BTs,and to elaborate the differences between them.METHODS All patients with BTs during the past 15 years were reviewed,and data were retrospectively analyzed regarding the mechanism of injury,diagnostic and therapeutic procedures,and outcomes.According to the injury mechanisms,the patients were divided into two groups:Blunt BT(BBT)group and penetrating BT(PBT)group.The injury severity,treatment procedures,and prognoses of the two groups were compared.RESULTS A total of 73 patients with BT were admitted during the study period.The proportion of BTs among the entire cohort with chest trauma was 2.4%(73/3018),and all 73 underwent thoracotomy.Polytrauma patients accounted for 81.6% in the BBT group and 22.9%in the PBT group,and the mean Injury Severity Score was 38.22±8.13 and 21.33±6.12,respectively.Preoperative three-dimensional spiral computed tomography(CT)and/or fiberoptic bronchoscopy(FB)were performed in 92.1% of cases in the BBT group(n=38)and 34.3% in the PBT group(n=35).In the BBT group,a delay in diagnosis for over 48 h occurred in 55.3% of patients.In the PBT group,31 patients underwent emergency thoracotomy due to massive hemothorax,and BT was confirmed during the operation.Among them,22 underwent pulmo-tractotomy for hemostasis,avoiding partial pneumonectomy.In this series,the overall mortality rate was 6.9%(5/73),and it was 7.9%(3/38)and 5.7%(2/35)in the BBT group and PBT group,respectively(P>0.05).All 68 survivors were followed for 6 to 42(23±6.4)mo,and CT,FB,and pulmonary function examinations were performed as planned.All patients exhibited normal lung function and healthy conditions except three who required reoperations.CONCLUSION The difference between blunt and penetrating BTs is obvious.In BBT,patients generally have no vessel injury,and the diagnosis is easily missed,leading to delayed treatment.The main cause of death is ventilation disturbance due to tension pneumothorax early and refractory atelectasis with pneumonia late.However,in PBT,most patients require emergency thoracotomy because of simultaneous vessel trauma and massive hemothorax,and delays in diagnosis are infrequent.The leading cause of death is hemorrhagic shock.

Silent Sinus Syndrome: Clinical Findings and Differential Diagnosis

The Silent Sinus Syndrome (SSS) is a rare condition that causes facial asymmetry, unilateral enophthalmos and diplopia. It is thought to be secondary to chronic maxillary sinus atelectasis (CMA) with reabsorbed bone and subsequent displacement of the orbital floor. Such anatomic modifications occur over time, and therefore it is possible to encounter different stages of the same disease with or without orbital displacement. Clinical findings can be unclear so it makes sense to recognize potentially evolving SSS while other disturbances have to be ruled out. Our purpose is to underline clinical findings for different diagnosis and proper management. We consider Functional Endoscopic Sinus Surgery (FESS) indicated in CMA and SSS to halt the progression of the disease. Nevertheless restitution treatment of enophtalmos due to orbital floor displacement involves plastic reconstruction of the floor of the orbit via transconjunctival approach. We report a case of SSS and discuss distinctive features of non-neoplastic lesions involving the maxillary sinus that should be considered for differential diagnosis.

A Working Classification of Retraction for the Whole Tympanic Membrane

Objective: To formulate a reliable classification of tympanic membrane retraction which is easy to use but capable of detecting small differences in retraction. Study Design: Prospective study. Methods: The classification was developed from observations dividing the drum into 3 areas: the pars tensa anterior to the malleus, type I, posterior to the malleus (subdivided into upper and lower) type II, and attic type III. The subclassification on paper is more complicated but using a database it is easy to use. The classification is automatically calculated by the database which can also be converted to numerical form. The classification also allows documentation of active disease in retractions. Photographs of seven retracted ear drums were incorporated into the database and ten otolaryngologists asked to classify them. Five were asked to reclassify the retractions in the same way after 3 months. Results: Intra class correlation was significantly high (>0.9) for pars tensa, attic, and for bony erosion. Cronbach’s alpha values were also high (>0.9) in all groups. Retest values were evaluated with Wilcoxon’s signed rank sum test establishing that there was no significant difference in results. Conclusion: The classification shows reliabiliy and validity allowing detection of small changes in tympanic membrane retraction especially affecting the pars tensa but allows classification of the whole tympanic membrane.

Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis

Subclavian artery thrombosis is a rare complication of clavicle fractures. We reported a 20-yearold man who was admitted to the emergency room after a road traffic accident. He was a pedestrian who was initially hit by a bus and after he fell down on the road, he was run over by a car. On evaluation, he was found to have multiple facial and rib fractures, distal fight humerus and right clavicle fracture. Significantly, right radial pulse was absent. After further evaluation including Doppler studies and an angiography which revealed complete obstruction of right subclavian artery just distal to its 1 st portion, the patient was urgently taken to the operation room. A midclavicular fracture was adjacent to the injured vessel. We established proximal and distal control, removed damaged part. After mobilizing the subclavian artery, an end-to-end anastomosis was made. Then open reduction and internal fixation of right distal humerus was performed. The rest of the postoperative course was unremarkable. To prevent complications of subclavian artery thrombosis, different treatment modalities can be used, including anticoagulation therapy, angioplasty, stenting and bypass procedures.